2Department of Pathology, Monastir University Hospital, Faculty of Medicine of Monastir, Monastir, Tunisia
3Department of Pharmacology, Faculty of Medicine of Monastir, Monastir, Tunisia
Routine laboratory tests revealed markers of inflammation (CRP and ESR concentrations, and leukocyte counts) significantly higher than normal values, and elevated creatinine concentration and anemia related to her renal failure. Biopsies of skin lesions showed vacuolar interface dermatitis with necrotic keratinocytes and a predominantly lymphohistiocytic inflammatory infiltrate with neutrophils and eosinophils (Figure 2).
Based on the clinical and histopathologic findings, we diagnosed multifocal FDE due to mefenamic acid. Patch tests performed with mefenamic acid, 30% in petrolatum, applied on healthy and lesional skin were positive on lesional skin (Figure 3). The patient was advised to stop taking mefenamic acid and no further episodes of skin inflammation were reported after a mean follow-up of 1 year.
FDE can affect any age group from childhood to older age, but most commonly affected individuals are aged 20–40 years . Association with HLA-B22 has been reported . Cutaneous and mucosal lesions appear minutes to hours after administration of the sensitizing medication . They are observed most frequently
The lesions are often asymptomatic, but burning and pruritus at the involved sites are reported [12, 14].
Rarely, systemic signs and symptoms such as malaise, anorexia, fever, diarrhea, nausea and abdominal complaints occur.
A wide range of drugs can trigger FDE, but the most common ones are antibiotics (particularly co-trimoxazole), anticonvulsants, and analgesics.
The most common offending agents include antimicrobials mainly co-trimoxazole, nonsteroidal anti-inflammatory drugs, and antiepileptic .
Mefenamic acid, an anthranilic acid derivative, is a nonsteroidal anti-inflammatory anti-rheumatic drug. It has analgesic, antiphlogistic and antipyretic effects via inhibition of prostaglandin synthesis. It is used to treat acute and chronic pain such as in rheumatic diseases, primary dysmenorrhea, after trauma and surgery as well as muscular and spinal pain.
Mefenamic acid is frequently taken without any medical advice. The association of the drug with a possible FDE may be difficult because the use of mefenamic acid is occasional and usually forgotten by the patients. Only few cases of PFE induced by mefenamic acid have been reported [1,2,15]. In the diagnostic work-up of fixed drug eruption, provocation tests represent the gold standard . Patch testing with the presumed drug will give positive results mainly when it is applied to the affected skin. In our case, patch tests with mefenamic acid, 30% in petrolatum, applied to lesional skin were positive. However, the sensitivity of patch-tests with drugs in FDE does not exceed 40-50%, and negative responses in patch-tests do not rule-out diagnosis of FDE .
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